Fort Dearborn - Chicago Photo Forum

Dearborn Station, 47 West Polk Street M-7

Chicago, Illinois 60605 (312) 922-0770 www.chicagophotoforum.org

APPLICATION FOR MEMBERSHIP

NAME ___________________________________________________________________________________

(First) (Middle) (Last)

ADDRESS ________________________________________________________________________________

(Street) (City) (State) (ZIP)

EMPLOYED BY: __________________________________________________________________________

Business Address: __________________________________________________________________________

(Street) (City) (State) (ZIP)

PREFERRED ADDRESS FOR FORUM MAILING LIST:

__________________________________________________________________________________________

PHONE: Home ________________ Business __________________ E-Mail __________________________

I intend to use the following Forum facilities: Darkroom ______________________ Studio _____________________

Please List Professional Photography or Camera Club affiliations, past or present:

__________________________________________________________________________________________________

I have attended the following photographic school(s):

__________________________________________________________________________________________________

List in order of preference, committees you would be willing to work on:

(1) __________________________ (2) ___________________________ (3) ___________________________

List two personal references (need not be photographically related):

__________________________________________________________________________________________________

(Name) (Address) (Phone Number)

__________________________________________________________________________________________________

(Name) (Address) (Phone Number)

If elected to membership, I agree to be governed by the Constitution, By-Laws and House Rules of the Ft. Dearborn-Chicago Photo Forum. I understand that it is my obligation to contact the Membership Chairman to schedule an interview to join the Forum. My obligations for dues shall continue until the Board of Directors has received my written notice of resignation from the Forum.

______________________________________________ ___________________________

(Signature) (Date)

I attach my check to cover the following:

 

Initiation Fee                                                                                   $ 35.00 $ _________________________

Dues                                                                                                $ 20.00 $ _________________________

Darkroom/Studio (Facilities) Fee                                                     $ 25.00 $ _________________________

Locker Fee (Per Locker, 1 Time - Darkroom/Studio Users Only)    $ 20.00 $ _________________________

TOTAL                                                                                                        $ _________________________

Approved by Board of Directors __________________________________

(Date)